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Gold, incentives and meh

GPs should be ‘pleased’ when small practices close, suggests NHS's top GP

Exclusive The leading GP in NHS England has suggested that GPs should be ‘pleased’ when small practices close, as there are ‘too many’ of them struggling to meet patient demand.

Dr Arvind Madan, NHS England director of primary care, stood by comments attributed to him where he said ‘most businesses are pleased to see rationalisation of providers’, which he linked to small practices closing.

He also stood by comments where he suggested that GP practices should take some blame for a failure to recruit.

Dr Madan said that practices should be moving towards working at scale, and that there was a ‘degree of responsibility’ for them to not ‘passively wait for the system around them to change’.

Leading GPs expressed fury at the comments, pointing out that many small practices don’t have the time or headspace to transform, or their location may prevent them from doing so.

Pulse found earlier this year that 1.3 million patients had to move surgery after their own had closed, following 450 closures over the past five years. In 2013, only 18 practices closed.

However, in the comments attributed to Dr Madan, he suggested GPs should be ‘pleased’ about this. He said: ‘Most businesses are pleased to see a rationalisation of providers, as it makes the remainder more viable. In the general practice market, there are too many small practices struggling to do everything patients now want for their families in a modern era of general practice.’

In an exclusive interview with Pulse, Dr Madan stood by these comments and explained: ‘General practice here is built on a foundation of 7,400 small and medium-sized businesses. In all markets, there is some degree of difficulty for a proportion. The environment is a big factor within that. But actually, I think we would all like modern, thriving general practice available to us and our families.’

He said grassroots GPs should embrace the rollout of between ‘1,000 and 1,500 “primary care networks”, covering 30,000-50,000 patients’, which will have ‘multidisciplinary teams’, formed of nurses, mental health workers, and clinical pharmacy teams and expanded diagnostic facilities.

He added: ‘I think it is our job to help every practice on this journey. There is a degree to which the central national team can create the environment in which all practices can thrive.

‘But there is also a degree of responsibility within practices, which I am sure they will accept, to take up the opportunity because I am not clear that passively waiting for the system to change around them is sufficient.’

GP leaders were furious over the comments. Dr Zoe Norris, chair of the BMA’s GP sessionals subcommittee, says: ‘I’m surprised and disappointed. I would have more respect for NHS England if they were upfront about their agenda.

‘Many GPs have felt for a long time that there is only one direction of travel being pushed by NHS England: away from small practices and into groupings of a defined size as primary care networks.’

Dr Rachel McMahon, England Conference of LMCs chair, said practices are not always able to transform. She added: ‘To suggest practices in these areas have the headspace available to drive forward major transformation when all their efforts are going into just keeping the doors open seems naive to the issues these GPs are facing.’

Dr Mark Sanford-Wood, BMA GP committee deputy chair, said: ‘Small practices are often delivering the best standards of care to patients, who are seeing the same doctor who is embedded within the community and has a detailed knowledge of individuals’ medical history.

‘While the BMA believes there is a benefit in practices working together across an area, this needs to be done in a positive, mutually beneficial way, in which full support is provided to practices. For such systems to thrive, all parties, not least patients, must benefit.’

Pulse revealed in 2016 that Paul Twomey, medical director of the Yorkshire and Humber NHS England area, sent an email to practices saying vulnerable practices must ‘transform…or be allowed to fail and wither’. NHS England immediately denied this was national policy. 

Readers' comments (69)

  • Lost for words. What about CONTINUITY you MORON. General Practice has thrived in small groups in the past. But in the last five years (as we can now clearly see ) it has been deliberately pressured and attacked and targeted.

    If group so 30,000 patients were ideal they would have naturally evolved in the past- the fact that they haven't speaks volumes. Bigger means worse - worse for doctors and worse for patients.

    Pass the sick bag.

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  • Not a helpful comment, overall. What about those areas where expansion or combination is impossible - i.e. rural and semi-rural ones? Where the GPs delight in knowing all the patients; where the patients delight in always being seen by someone who know them (or perhaps, always by the same doctor).
    Remember also - our notes are only the tip of the iceberg of our knowledge about the patient: all the rest of the un-noted (but personally remembered) knowledge is there and being utilised in the small practices, providing the best possible quantity and quality of continuity of care.

    Or doesn't that matter, suddenly?

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  • The good news is my small practice has capacity, available appointments, personal lists and triage by the Dr himself. Last time I looked less OOH and A/E attendance, and a better than national 2WW conversion rate.

    Also didn't some clever study recently come up with broadly similar data for small practices.

    Feel free to visit Grimsby where I work, but guess he has no idea where it is on the map far less the ability to find it!

    Better be quick though as comments like these do nothing to encourage me to stay 1 minute longer than I have to as I'm such a valued member of the medical profession as a GP in a small practice.

    As Rowan Atkinson said "I spurn you like I would a rabid dog!"

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  • Professional prostitution and irrational ass licking allows you to get to the top but you tend to slip on your own scum or grease as you would like to call it.
    The 'Family' was lost out from 'Family Medicine' because of leaders like this one.
    I propose him as the 50th most influential so when he slips he has 49 still more stinky ones on top.

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  • We were quite happy as we were until the last few years of punishment funding cuts and stoking up of demand. The job hasn't changed in essentials - just the (lack of) support, funding and stability with the new political agenda. Do any of these "leading GPs" consider that they might not actually be right and that this forced direction of travel might be as damaging as some of us fear and certainly not applicable in all areas and types of practice? Any new funding is now only for those playing the current "locality working" or "open all hours regardless of need" game and then we are blamed for failure to recruit!!! Regarding the presumption that he knows what sort of general practice we all want - Dr Madan does not speak for me.
    Here's a thought - ask patients what sort of general practice they want and are prepared to fund then work towards that.

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  • By the pricking of my thumbs something evil this way comes.Here comets the end of days for the NHS,and the beginning of Yankee based HMOs.Meanwhile we are all a decade of all comparable professions in terms of renumeration and t&cs.The country is unattractive to Health care workers throughout the world.

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  • Completely flies in the face of recent evidence that suggest continuity is very important. Especially as patients get older with more comorbidities. It’s short sighted.

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  • THE HURLEY GROUP HAVE 100,000 patients/13 practices.

    Is he still a director of this group? if so then some might suggest a potential conflict of interest??

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  • Clear evidence of the political desperation to close small practices despite the mounting evidence that continuity of care provides benefits far beyond those that may exist by forming bigger practices. Business consultant/MBA drivel lapped up by thick politicians and their medical lackeys.

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  • Vinci Ho

    Where you sit your arse will govern which way your brain goes . Whether you believe something or not , it is not important anymore.
    As long as you live on the reward granted by your emperor, you take on his worries and concerns.
    Sigh , the conscience and honour of some are out for sale......

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  • Moron!

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  • The clarity that NHSE actively want our businesses to fold and that continuity of care is no longer important (despite evidence to the contrary) in order to fit in with this years policy vision is helpful. Transparency is good though I suspect he was forced to be transparent.
    To assume anyone should be pleased is utterly ludicrous and delusional. He must listen only to the sound of his own ambition.

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  • http://hurleygroup.co.uk/category/about/gp-partners/

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  • I think this is a resigning issue and needs a wider audience.

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  • To think he may benefit from policy direction.....

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  • General practices of any size are not "most businesses" and GPs might be 'pleased' if this fact was acknowledged by our leaders. The closure or impending closure of small practices in our already underdoctored area causes my partners and me to feel terror and despair at the extra workload we're going to be obliged to take on; with no prospect of recruiting, no amount of money can buy us the time we need to provide care to large numbers of extra patients whose care may need to be overhauled as they've come from struggling practices.

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  • This is so serious. It needs the strongest possible reaction from the RCGP and the BMA.

    This has to be a line in the sand. All is lost otherwise.

    Who does this man think he is?

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  • Rogue1

    He cant be a GP? Was he ever a GP?
    I cant believe anyone who has ever worked and committed themselves to the job could actually come out with such drivel !
    It shows complete ignorance. Absolutely flabbergasted

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  • Will it be a Knighthood or Lord

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  • Who made him director. foreign doctors have worked in small practices with big list and working in deprived area. how dare he insult them. he says "gps will be pleased" so small practices are run by ghost or gps.why would they be happy of their demise? all comments above show how happy they are. they will be happy with his derogatory comments. get dr madan out of office today please. I presume is to look after primary care.

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  • Leading does not mean top!
    The best primary care system in the world being ruined
    Some things are not improved with economies of scale

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  • Come on Pulse. Lazy headline. We all know a 'top GP' is one whose patients say "thanks, you're a top GP" on leaving the consulting room. I see that comment in the 360 feedback of appraisees working in the sort of practices he seems to despise. It's rare to see it relating to a Bum on Seat Conglomerate GP. Twit GP (other vowels are available) may be more apt.

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  • I feel sorry for the patients in his practice who obviously receive no continuity of care.

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  • Nhsfatcat

    Wow! Partner in Hurley Groups presumes he knows what's best for all practices. As ignorant as the SoS and DH on this issue. Massive conflict of interest. How about TOP GP in NHSE considers what is best for all patients and asks for funding and scraping of useless regulation. No gongs for being sensible! Traitor

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  • please look at dr madan's practice nhs choices web site. see how patients review his practice.

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  • What’s this nonsense about ‘Top GP’ etc - who gives these designations?? R the rest ‘fool’ GP’s ??

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  • Anyone can blabber !! Small practices are the ones who work the hardest, provide personal care to patients and serve the community. Who is this chap ??

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  • David Banner

    Delighted to face unlimited liability when forced to close.
    Chuffed to pay off the entire lease from my own pocket.
    Tickled pink to pay all my staff redundancies
    Thrilled to enter personal bankruptcy.
    Yep, small practices clearly will welcome closure with open arms.
    What a callous, stupid, insensitive man.

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  • National Hopeless Service

    What an utterly disgraceful comment. If my small rural practice were to close it would be an unmitigated disaster for the patients and longterm who have a major financial impact on secondary care costs when continuation of care was lost. This man has turned into a pointless manager.

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  • No Need for me to comment- see all above comments which say it all
    see Hurley group reviews 2 stars out of 5
    " No one answers the phone, it just rings out. I’m changing gp at this point."

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  • Ar5ehole

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  • If the BMA aren't onto this like wolves cancel your subscription.

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  • How sad and totally incorrect.
    Not in touch with real life caring general practice which you are systematically destroying. No evidence for your statement. It time for proper caring hard working Gp to stand up and say NO. Enough is enough. Our Gp leaders have failed us and many have kept their lead positions on CCG and LMC’s , resigning from their practices and working as Locums. No credibility !

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  • Ah top gp eh. Good luck with that.
    As partnerships go maybe the lackeys will realise the emperor has no clothes and charge market rate?

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  • Generally we are still a 'green ans pleasant land' .
    If we allow the PC driven metropolitan elite 's to Take over--'God help us all'.

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  • Beyond belief.

    What is the point of being a GP without developing the knowledge of people and families that comes from working for long periods at a reasonably small scale?

    Like many other commentators here - I simply despair.

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  • Dear Pulse,
    Please cease to refer to this utter waste of space as a 'top GP'.
    I suggest something like 'top bum licker' because it's clear who is yanking his chain beyond the ivories of NHSE.
    An utter disgrace and a traitor to his profession and any notion of good holistic patient care.


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  • Resign


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  • Yet another open goal that our "Leaders" should be hammering home. What is depressing is that we on the front line are feeling so helpless in the face of this abuse ( add GMC, CQC, NICE and that's just for starters) Joe Public has no idea what is going on with this agenda and where it inevitably will lead and whilst some may say they will get what they deserve, the matter needs to be brought out into the public domain. If any up and coming journalist working for Panorama was wanting to make a name for him/herself "The Wilful Destruction of the Main Pillar of the NHS" would be an eyeopener! Get all these punters who preach Cherry picking Apps, casting aside hardworking popular small GP units, the use of every man and his dog apart from the one person that patients want to see etc. Subject them and the consequencies of their proposals to proper scrutiny and at least get a debate on the subject. This unhealthy abuse really has to be addressed. Can you imagine the Firefighters Union putting up with this! If the whole shooting match goes to pot at least hold the feet of the guilty parties to the fire!

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  • He has made the terrible mistake of assuming small means poor. That makes him a moron. Not only are there some excellent small practices, but small practices are more likely to be excellent when considering important clinical data. The worst practices in my areas are mostly large. (I don’t work in a small practice)

    Finally he has assumed that the other businesses (practices) want to add customers because that makes them more viable. It might apply to Tesco or Amazon where prices can be set to make sure customers are profitable, but for most GP surgeries with limited space, little infrastructure investment and difficulty recruiting quality GPs; expansion is certainly not profitable or stabalisibg. For that system to work the price per gms patient must be pushed up to the point where practices compete for them. That is unlikely to happen soon.

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  • It is a mystery why his loquacious partner and another of our illustrious LEADERS, Lady Wessely aka Clare Gerada, has not made a comment

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  • The essence of general practice is continuity - it's the only reason the gatekeeper system works. Without it care will suffer and secondary care pressures will rocket. The man is a dangerous fool

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  • Agree with almost everyone's comment earlier,but has anyone given a thought on what are the alternatives? Does everbody thinks that current model is viable? I accept that our current model gives continuity, personalized care and patients love it which no super practice will ever give.
    But we are dealing with question of our existence. Has anybody given thought on from where increased funding is going to come which we need desperately? Current situation we are in is because of years of under funding and no government is going to give increase in funding in real terms.
    So either we keep on accepting squeeze on our take home pay and continue delivering care as per our current model & be happy that our patients love us or we embrace the changes which are needed for our survival.
    Patients will be very happy for us to keep on giving personalised care as long as they don't have to fork it out of their pocket . They don't care one bit about our stress / reduction in pay/ whether we loose our job or die.

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  • Commented earlier and to be honest my only concern for alternatives is I and my elderly parent likely to be using the service once retired! (hopefully a way off though)

    My partner retired at short notice and my small practice recruited (poached) from big practice actually as she fancied a more civilised work load and environment.

    Would stay longer if felt valued but powers that be don't so I don't either.

    Didn't sign up for all this crap as a medical student.

    Unfortunately patients wont like the change but I'll be long long gone!

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  • From NHS Choices:
    Rude staff and always rude

    I started stop smoking program with this surgery and in middle of my course they stopped my prescription twice. Staff was sending me back and forth over and over which wasted my time and energy. Still were not able to resolve problem.

    Staff is always in extreme anxiety and rude. I saw them shouting on other patients specially kids.

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  • Great idea. So please explain why small practices consistently perform better in almost every way but particularly in patient surveys.
    And please explain how it is that other European countries with more successful health care systems still mainly have very small practices and mostly single handers.
    And explain how now we know that continuity matters how exactly is it acheived in a big practice.
    Answers awaited with no expectation of a result.
    This is the 'tyrannisation' of our profession

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  • Practice does not read correspondence

    Sent an email for a modified amount of medicine because the GP has a habit of hitting print instead of reading what I actually need. I clearly laid out how many pills I needed and today discovered i've been given too much of one and not enough of the other.

    I went at 5.30pm to speak to reception and was told there was no one to help despite the practice shutting at 8pm. I was told to send another email despite the content of my emails being ignored. I have been telling the practice for months that I am leaving the country for an extended period and have been assured at every point that when i asked I would get the amount of medicine I needed. Today I was told that this was not possible, that the GP only issues in 1 month batches. For some reason the receptionist assumed I was after contraceptives and not my usual medication.

    The receptionist walked off while I was writing down my prescription and went to do his dishes. He ignored me when I called and asked for the name of the person he said I'd need to phone tomorrow. Another staff member had to give me her name.

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  • Terrible service

    No one answers the phone. Can't get help. No appointments. The most disorganised practice I have ever come across. Just awful.

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  • Very poor patient care and experience

    I have been a patient with this surgery since it opened some years ago. Whilst they ware also running the walk in centre things were quite good.

    Since then getting through on the phone is almost impossible. Getting a convenient time for an appointment requires a three week wait.

    using the online appointment system is just not fit for purpose. I tried to use it and was given a random date and time. No choice etc: An appointment in the middle of the day doesn't work for me.

    The only way to be assured of getting an appointment is to visit the practice to book an appointment.

    Issues about the reception staff being unhelpful and uncaring are true. Whilst I was there a visibly ill and frail person came up and asked for an appointment and was told a date some 2 weeks later. When challenged she then said I will put it on a card for you.

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  • Enjoy your 30 pieces of silver Madan.

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